NCC203204_NOI Signed Certification_20200728

NCG1 Notice of indent (N01) Certification Form
Directions:
Print this ionn, complete, scan and upiaad tothe electroi is NO I.
Then, mail the original form to the NC DENALR Stormwater Program (with $100 check if paying by check) at:
Division of Fnergy, Mineral.8; Land Resources Stormviater Program
512 N. Salisbury Street, 5"' Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Pei -NC Getletal Statute 14.3-215i 68 (i), uny person who knowingly makes arty false stata merit, r-epr-esentation,
or- certifica ion in any apphcafion, record, report, plan, or- other document filed o7" r"eph-ed to be nlaintalaed
undet- this & icle or a rile itnplementing this Article ....shall be guilty of a Class 7 misdemeanor which may
include aline not to exceed tell thousand dollars ($10,G00).
Under penalty of lavtl, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the c0nst1_c1cti011 activities of this project, for satisfying the
regUirernents of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
( The information subm tted in this Not is, to the best of my knoviledge and heJef, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, .or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCG010000General Permit and the approved Er•osian and
Sediment Control Plan.
i If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater P011utiOn
Prevention Plan) of the NCG010000 General Permit. I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and undei-stan.d that coverage under
this permiE vvd1 constitute the permit requirements forthe discharge(s) and is enforceable in the
same manner as an individual permit.
Narne of Projec'�: V L. 5_
Legally Responsible Organizational Entity: ��-� Irff CM, �G� 0 }- Fi mc*..Q,�
Legally Responsible Person: 7)6(kr) I��Ekg7
Title of Legally Responsible Rerson: p- �i` +
*Signature: �ry, ,� „w�, Date: `i � 23
*Print Name and Title of Signe.ci if Auihoi_ized
IndividUal D[ff{e1'S f!"o171 Pcr"1i�i t12e;
If/1,I)O TAWT A101 E, T hl s fort°r� r17trM I e signed by a r esl�ol�sible carpor"ctte officer' i'ha� ota�r�s �, operates tl�e
C(7n" ti'uctln.'-r activ.'tj! sVch os 0 f 11-&Sident secl'etar) j i-ousur el, o'i-Vice pi-esiL+L-'n , Or a 177r1ii L'''1 t'17f7i' is
authorized in accclydance with Part h Section 13, item (6) of the NEG010000 perroiL
Fvr more informmotion on signatory see Pratt li! Sec ion R, Item (6, of OI A1CGc7_r6,090 pep-17-1h